THE CANCER WARD by Alexander Solzhenitsyn. Translated by Nicholas Bethel and David Burg, Noonday Press, New York, 1974. (Russian edition 1968)

Reviewed by Del Meyer, MD

This work of fiction is based on the author’s own experiences as a patient in a cancer ward in the 1950's, but it speaks to us more clearly with each passing year as our country grapples with the problem of providing basic health care for all.

As the story opens, Nobel laureate Solzhenitsyn’s Soviet world of 40 years ago seems like a strange and foreign place indeed, with its detached, impersonal, "universal free health care" system which serviced frightened powerless patients with competent but distant doctors whose passionless demeanor would have served them as well if they had been engineers or plumbers.

The chapter titled "The Old Doctor," is particularly prophetic. A 75 year old physician, Dr. Oreshchenkov, mourns the extinction of the family doctor in modern Soviet medicine. He characterizes this practitioner of a bygone era as the "most comforting figure in our lives...a figure without whom the family cannot exist in a developing society. He knows the needs of each member of the family, just as the mother knows their tastes...the kind of person to whom they can pour out the fears they have deeply concealed or even found shameful... But he has been cut down and foreshortened. [It is very difficult] to find a doctor nowadays who is prepared to give you as much time as you need and understands you completely, all of you." A fellow physician and patient responds, "All right, but...they just can’t be fitted into our system of universal, free, public health services." Dr Oreshchenkov retorts, "Universal and public--yes. Free, no." The colleague replies, "But the fact that it is free is our greatest achievement."

Dr Oreshchenkov then gives us the real message for our time: "What do you mean by 'free’? The doctors don’t work without pay. It’s just that the patient doesn’t pay them, they’re paid out of the public budget. The public budget comes from these same patients. Treatment isn’t free, it’s just depersonalized. If the cost of it were left with the patient, he’d turn the ten rubles over and over in his hands.

The Author then describes how he feels the health care system should be. He felt that primary treatment should be at the expense of the patient, but hospitalizations or costly procedures should be free. Then patients would be in control of when and how often and from whom they should seek medical treatment. "With the right kind of primary system,...there would be fewer cases altogether, and no neglected ones..." Each patient could be treated as a whole person instead of a collection of diseases, to be tossed from specialist to specialist like a basketball.